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Patient Intake Form CV19

Personal Info

Contact Info
Emergency Contact
Doctor

Medical Info

Insurance Info

Conditions

Emotion / Memory
Female Health
Oncology
Energy Level
Energy
Feet
Well Being
TMJ (Jaw)
LIV/GB (Wood)
LU/LI (Metal)
KID/UB (Water)
Male Health
Treatment Goals
Infectious
Health Questions
COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Area of Complaint
Headaches
Family History
Blood
Cardiovascular
Endocrine
Gastrointestinal
Hearing
Immune
Kidney
Musculoskeletal
Neurological
Reproductive
Respiratory
Skin
Miscellaneous

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